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Mindfulness Meditation

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If you have had chronic pain a long time, I assume your psychologist or clinical social worker may have told you about Mindfulness Meditation. Some of them teach Mindfulness Meditation. Hopefully there have been more centers spreading across the country that do. The work was started by Jon Kabat Zinn, PhD, now a Professor of Medicine Emeritus at the University of Massachusetts Medical School, and his neuroscience associates in Boston in 1979.

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Jon Kabat-Zinn started out as a molecular biologist, studying under Nobel Laureate Salvador Luria, but his interest in meditation drew him towards the study of how the mind facilitates healing. Now a Professor of Medicine Emeritus at the University of Massachusetts Medical School, Dr. Kabat-Zinn has focused his research on the benefits of mindfulness meditation in cooperation with clinical treatments for patients with chronic illnesses and stress related disorders.

Recent studies from Massachusetts General Hospital have shown that the MBSR program can produce thickening in particular regions of the brain important for learning, memory, executive decision-making and perspective-taking and that certain regions of the brain like the amygdala, which involves threat and fear circuitry, get thinner.

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Dr. Kabat-Zinn has written 4 books, translated into over 30 languages, including Full Catastrophe Living; Wherever You Go There You Are, Everyday Blessings, and Coming to Our Senses. His early book is still a classic book in the field:

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And this week, a package arrived from a dear fellow whom I have followed for many years of unimaginable pain. His strength of mind survived better, I think, than mine. He is just too cool, in the face of major health obstacles. For a few months, he and his wife are currently stationed out of state awaiting a major operation. I had mentioned Mindfulness Meditation to him and he sent these two lovely gifts for those of us who need all the cool help we can get:

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AND

They were a hit with my patients all day; they even magically entranced a senior who said that of course she’d never do them. She couldn’t resist. Papa can do some with his grandsons. We have all found distractions help. These are mesmerizing.

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They cannot be resisted. They are delightful, and once you peek at them, they grow in your mind, existing in the unconscious behind all those crumpled up crowded thoughts. Interesting, alien thoughts of fun! patterns and designs, that you will fill soon with colors, and of course the aliens of fun will do their magic to thoughts that may be painful. Dissociating from pain. They become the mandalas of today, expanding your higher consciousness into abstraction, absorption into silence and freedom from thought. Exactly like the purpose of Tibetan sacred sand mandalas, I would assume.

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Just glancing at them today, they are already regrooving the brain back to delightful, fun emotions, because they are wonderfully hypnotizing. I wasn’t aware of bringing them subconsciously along with me until hours later, but there they are. All smiles.

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They got everyone hypnotized and tuned in, just looking at a few pages. I can easily see how they would hypnotize and delight you. Whatever they do, they look like fun! Simply joyful fun! And fun helps us take our mind off pain. Just to see everyone’s face light up in joy as I showed them a few pages. Have I made it clear how much fun it was? These drawings are as interesting and as smart as they can be.

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Pain kills

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Cutting back my patient’s opioids when they were helping, when there is no better alternative, none better – it is the most painful thing I’ve ever been asked to do as a doctor. Withdraw necessary medicine. On orders from the federal government forcing me to harm my patient.

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Orders. Cold as a steel gun held by DEA Swat team bursting into my office if I don’t act on government orders. Certain dictatorships treat citizens that way.

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Congress is pushing this opioid bust very hard.

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That is demagoguery

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I am pained and suspicious in several ways.

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Legal nationwide precedent.

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A precedent in government, deciding for each individual person, without good faith history and examination of each, now orders each person’s medical treatment.

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It overrides judgement. I feel my judgement specializing for decades in pain management, with or without use of opioids, using comprehensive multi-specialty approaches has always chosen excellence in the field of pain management, in accord with State and Federal guidelines until this new one, and within the best practices of the American Pain Society.

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Best practices are irrelevant. Choke on that one. The lack of options is impossible to swallow. It is life-changing for the most severely disabled patients across the country.

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It has nothing to do with the subject: pain control.

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Nothing to do with helping to relieve pain.

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It causes grave harm to my patients and their families and sets an astonishing precedent among healthcare insurers to never allow more than the guidelines; the federal CDC-invented, arbitrary, pseudoscience, one-size-fits-all guideline for opioids because:

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the government can’t deal appropriately with the heroin epidemic and the war on drugs. They ignore results from countries that have done more enlightened research to point the way.

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Demogogues order doctors how to treat everyone. This country is has done what China and Russia have done to their citizens. I am in shock. My patients are in shock. Aghast. Feeling forced to bend over and swallow an undemocratic, unscientific piece of

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This used to be a free country with certain rational sets of behavior and one that recognized a need for pain specialists. Only recently did it create specialists in pain management. Specialists who get ignored. Does this happen in every other field? Shouldn’t we all care no matter our expertise because we may all have bad pain if we live long enough? Chronic noncancer pain. What if some federal agency starts ordering you that dialysis will be allowed less often?

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None of us gets away from the grip of the irreligious opioid guidelines. Will we have intractable pain at some time in our lives? Will we allow government to dictate that you or your spouse or gram cannot be given the dose that has safely helped for years? The guidelines were forced on us.

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Insurance will not pay for more.

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This needs to be discussed as a presidential election debate issue.

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Demagogues appear at times of unrest across the country. Politicians may feel forced to bow to the anti-opioid groups, angry because of the heroin epidemic and at how badly addiction treatment is neglected in this country.

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But for pain patients not addicts, to be subjected to directives from federal agencies, CDC and DEA, how do we object to this unscientific, irrational precedent? At least debate it on a presidential level.

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Drug abuse, addiction, pain management and healthcare insurance as it pertains to these new federal opioid guidelines presume to treat pain but force us all into a cage of irrational pseudoscientific dictates. And we are forced to mangle the finely adjusted treatment of your pain, your spouse or your granny’s pain. We’ve slogged through so much to get there. It’s tough to find the right balance with chronic daily pain.

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Those running for president:

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What is the candidate’s position on this unprecedented fiat that dictates your maximum morphine equivalent daily dose (MEDD) you can receive? It is a dose that is far less than you’ve been on for years that had been helping.

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Is this creating unprecedented pain among 50 million Americans with chronic pain?

Opioid Guidelines are Pseudoscience

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They do not pretend to treat pain

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CDC Opioid Guidelines limit opioids to

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90 mg morphine equivalent daily dose, MEDD

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Whose calculations will the DEA use against your doctor?

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Chronic pain is life altering. Opioid guidelines are life altering. The introduction of pseudoscience on a nationwide scale is life altering. Actually being the physician to reduce opioid doses to comply with arbitrary guidelines is life altering.

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The guidelines are intended to stop death and misuse from opioid overdose, not intended to relieve pain. About the same as taking drivers off the highway to stop highway deaths. We are just about back in the era of pain management before 1990.

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A nationwide mandate that affects the practice of thousands of doctors and the health and well being of 50 million people whom the authors have never examined, is life altering.

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We are all in shock. Guidelines don’t care about pain. CDC does not care. It’s all about death from overdose – tens of thousands of overdoses every year. Even when we calculate some magic pseudo-equivalent dose, just how are we to get from point A to point Z? It is not discussed. This anonymous treatment limit is an insult to our patients, and fails the standard of practice of medicine in this country that requires a good faith history and examination of the whole person, just to begin. Then to design a treatment plan.

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For example, how do we calculate the morphine equivalent daily dose (MEDD) of oxycodone? That can be tricky. Opioids vary from person to person, drug to drug and the tables used to calculate and convert from one to another all differ. How simple is that? Wouldn’t we rather be talking about opioid splice variants, anything, but this calculated number is based on pseudoscience, as explained in this publication:

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This critical paper is published by the Journal of Pain Research, which is open access peer reviewed. Why is this important?

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Let’s look at a few points:

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In 2014, Shaw and Fudin conducted a survey comparing various online opioid dose-conversion tools and found a −55% to +242% variation across eight opioid-conversion calculators.16 The standard deviations in these two studies alone exceeded many of the MEDD maximums that several states have employed to trigger consultation from a certified pain expert.8,17–19 These studies alone unequivocally disqualify the validity of embracing MEDD to assess risk in any meaningful statistical way. Outside of MEDD calculations, there are several factors that also require consideration, but that remain largely ignored. These include patient-specific attributes, such as pharmacogenetics, organ dysfunction, overall pain control, drug tolerance, drug–drug interactions, drug–food interactions, patient age, and body surface area.15 The bottom line is that as the scientific concepts upon which prescribing guideline authors depend are flawed and invalid, so are the guidelines themselves. As a result, we posit that these guidelines are disingenuous and highly unethical.

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Opiate overdoses unfortunately can occur at any dose, and patients are at risk on even low-dose opioids.

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Death can occur at any dose. There is no “distinct risk threshold.”

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The guidelines are intended to stop tens of thousands of deaths from opioid overdose, they are not intended to improve pain. Just as chronic pain seizes the brain, the opioid guidelines stop rational thinking and all your reflexes.

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The morphine equivalent daily dose (MEDD) of 90 mg is the maximum dose on the guidelines and affect everyone no matter how different your pain, your age, or your dose needs to be from another person, and regardless of how opioids differ from one another. Pseudoscience creates a huge problem. This is not only not evidence-based. There is no evidence at all.

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It’s not only opioid guidelines. Medicine is an art, not a science. Real people and medicines have real differences. The New York Times reviews a bookabout medicine by Abraham Nussbaum, MD, that says it well:

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“He notes that partisans of today’s much promoted evidence-based medicine must determinedly finesse the fact that medicine is riddled with flawed, incomplete evidence. The leaders of genomic revolution trumpet a future that keeps being postponed. Quality-control gurus abound, but their work often fails to yield actual quality.”

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Will the opioid guidelines bring a prohibition like the alcohol prohibition of 1928?

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For someone who has CRPS/RSD, any trauma including surgery can severely flare CRPS and/or cause it to spread.

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A young man in his mid 20’s was headed for surgery for acute appendicitis last night. He is resolving now, 24 hours later, with IV antibiotics as I suggested. He’s the first in his hospital, a major hospital in Los Angeles.

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Dad called me last night. Mom texted me reports of CT abdomen showing thickened wall of appendix, and all labs consistent with acute bacterial appendicitis: WBC’s elevated 15.1, elevated neutrophils consistent with bacteria rather than virus. Overnight, his generalized abdominal pain is now focal and much reduced, WBC’s are ~8, well within normal range including neutrophils, and he took a good walk in hospital. By day two, WBC count was 5, normal, no elevation in neutrophils indicating brisk response to antibiotics knocking out bacteria. He’ll go home on oral antibiotics probably tomorrow. I asked and was told he has chronic constipation which begs the question if it can trigger infection because of sluggish gut.

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Treatment & References

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1. If you have CRPS, then before any procedure small, large or dental, begin minocycline, a glial modulator. It was found in animal research many years ago to prevent flare or spread of CRPS.

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2. Antibiotics IV for the bowel.

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Below is a list of articles, most from the outstanding library of the Reflex Sympathetic Dystrophy Association. Their vast collection of publications is organized by subject. I strongly recommend donating to them.

“Conclusions and Relevance When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.”

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“Families who choose to treat their child’s appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn’t work, have expressed that for them it was worth it to try antibiotics to avoid surgery,” said Peter C. Minneci, MD, one of the authors.

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The appendix may be an important reservoir of bacteria to populate the gut with good bugs, our healthy microbiome.

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Why don’t we see appendicitis more often in adults?

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Surgery has very real potential dangers that may include infection, abscess, pulmonary emboli, cardiac arrythmias, brain damage from loss of oxygen, death. Years later, there may be chronic abdominal pain from scarring, adhesions of bowel, leading to more surgery to lyse the adhesions. Or acute pain from infarcted bowel when needed oxygen gets choked by adhesions that cause necrosis of segments of bowel, intense pain or perforation, possible death.

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Specific to laparoscopic surgery, I have seen two patients who developed years of intractable abdominal pain from the scope itself and in 2015 there was a recall of scopes across the country that caused death and/or antibiotic resistant infections carried on segments of the scope that could not be sterilized. Another concern, during laparoscopic surgery, they blow up the abdomen under very high pressures to float the organs away from the scope. Very high pressure.

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Constipation

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Let’s see a study to determine how often chronic constipation is present for years potentially causing the appendix to become inflamed. This young man will be taking a stool softener such as DSS or Colace (same thing), and if that doesn’t work then a prescription for Amitiza is something to consider.

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Antibiotics for uncomplicated appendicitis could save lives, prevent acute and long term complications, and lower healthcare costs.

November 30, 2015. . .Innate lymphoid cells (ILCs) are crucial for protecting against bacterial infection in people with compromised immune systems, report investigators. Their work shows that a network of immune cells helps the appendix to play a pivotal role in maintaining health of the digestive system, supporting the theory that the appendix isn’t redundant.

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The research team, a collaborative partnership between the groups of Professor Gabrielle Belz of Melbourne’s Walter and Eliza Hall Institute, and Professor Eric Vivier at the Centre d’Immunologie de Marseille-Luminy, France, found that innate lymphoid cells (ILCs) are crucial for protecting against bacterial infection in people with compromised immune systems.

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By preventing significant damage and inflammation of the appendix during a bacterial attack, ILCs safeguard the organ and help it to perform an important function in the body, as a natural reservoir for ‘good’ bacteria. The research is published in today’s issue of Nature Immunology.

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Professor Gabrielle Belz, a laboratory head in the institute’s Molecular Immunology division, said the study’s findings show that the appendix deserves more credit than it has historically been given.

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“Popular belief tells us the appendix is a liability,” she said. “Its removal is one of the most common surgical procedures in Australia, with more than 70,000 operations each year. However, we may wish to rethink whether the appendix is so irrelevant for our health.

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“We’ve found that ILCs may help the appendix to potentially reseed ‘good’ bacteria within the microbiome — or community of bacteria — in the body. A balanced microbiome is essential for recovery from bacterial threats to gut health, such as food poisoning.”

Professor Belz said having a healthy appendix might even save people from having to stomach more extreme options for repopulating — or ‘balancing out’ — their microbiomes.

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“In certain cases, people require reseeding of their intestines with healthy bacteria by faecal transplant — a process where intestinal bacteria is transplanted to a sick person from a healthy individual,” Professor Belz said. “Our research suggests ILCs may be able to play this important part in maintaining the integrity of the appendix.

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“We found ILCs are part of a multi-layered protective armoury of immune cells that exist in healthy individuals. So even when one layer is depleted, the body has ‘back ups’ that can fight the infection.

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“In people who have compromised immune systems — such as people undergoing cancer treatment — these cells are vital for fighting bacterial infections in the gastrointestinal system. This is particularly important because ILCs are able to survive in the gut even during these treatments, which typically wipe out other immune cells.”

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Professor Belz has previously shown that diet, such as the proteins in leafy green vegetables, could help produce ILCs. “ILCs are also known to play a role in allergic diseases, such as asthma; inflammatory bowel disease; and psoriasis,” she said. “So it is vital that we better understand their role in the intestine and how we might manipulate this population to treat disease, or promote better health.”